The AMIA 2003 Spring Congress entitled "Bridging the Digital Divide: Informatics and Vulnerable Populations" convened 178 experts including medical informaticians, health care professionals, government leaders, policy makers, researchers, health care industry leaders, consumer advocates, and others specializing in health care provision to underserved populations. The primary objective of this working congress was to develop a framework for a national agenda in information and communication technology to enhance the health and health care of underserved populations. Discussions during four tracks addressed issues and trends in information and communication technologies for underserved populations, strategies learned from successful programs, evaluation methodologies for measuring the impact of informatics, and dissemination of information for replication of successful programs. Each track addressed current status, ideal state, barriers, strategies, and recommendations. Recommendations of the breakout sessions were summarized under the overarching themes of Policy, Funding, Research, and Education and Training. The general recommendations emphasized four key themes: revision in payment and reimbursement policies, integration of health care standards, partnerships as the key to success, and broad dissemination of findings including specific feedback to target populations and other key stakeholders.

We conducted a feasibility study of an innovative Internet-based system, designed to support collaboration between patients and providers around cancer related symptom management. Our objective was to demonstrate the system's potential to enhance communication and clinical decision making between patients and their providers. Considering the high prevalence of cancer related symptoms and their impact on patients' quality of life, enhanced collaboration regarding assessment and treatment could significantly reduce illness burden. Twenty-seven patients with known malignancy and twenty-nine oncology clinicians were interviewed to identify functional requirements for the system. Patients reported the ability, willingness and desire to use a computer to help them manage their cancer related symptoms. Physicians recognized the potential of this system to improve communication and collaboration around symptom management, but voiced concern regarding a potential increased workload. Nurse providers had greater interest in reviewing symptoms online than did their physician counterparts. Patients in this study believe that using an Internet based system to report their cancer related symptoms would improve the quality of the care they receive. Our findings suggest that both patients and clinicians are concerned about the management of cancer related symptoms and would use Internet-based tools if they were shown to improve care.

Patients appear in the patient safety agenda in three important places: first and foremost as the individual most likely to experience the positive benefits of good care or negative consequences of unsafe care; second, as surveyors of quality of care indicators; and finally, through their presence as patient representatives on institutional safety committees. However, patient safety programs largely address provider-interests, and many times overlook patient preferences and needs. Active engagement of the patient in all aspects of the patient safety agenda is necessary for its success. Patient safety, then, requires: a comprehensive agenda informed by patient preferences and experiences; an informed and motivated populace; mechanisms integrate safe practices and patient preferences, and investment in safety-enhancing devices and care strategies.

The International Outreach Program of St. Jude Childrens' Research Hospital has been developing programs to help countries with limited resources develop treatment centers to treat children with catastrophic diseases such as pediatric cancer and AIDS. Cure4Kids (www.cure4kids.org) is the Internet learning network that delivers medical education to doctors and nurses on pediatric cancer and AIDS. The objective of Cure4Kids is not only education, but also to provide tools for communications and collaborations among individuals.

BACKGROUND: Despite the potential for rapid, asynchronous, documentable communication, the use of e-mail for physician-patient communication has not been widely adopted.
OBJECTIVE: To survey physicians currently using e-mail with their patients daily to understand their experiences.
METHODS: In-depth phone interviews of 45 physicians currently using e-mail with patients were audio taped and transcribed verbatim. Two investigators independently qualitatively coded comments. Differences were adjudicated by group consensus.
RESULTS: Almost all of the 642 comments from these physicians who currently use e-mail with patients daily could be grouped into 1 of 4 broad domains: (1) e-mail access and content, (2) effects of e-mail on the doctor-patient relationship, (3) managing clinical issues by e-mail, and (4) integrating e-mail into office processes. The most consistent theme was that e-mail communication enhances chronic-disease management. Many physicians also reported improved continuity of care and increased flexibility in responding to nonurgent issues. Integration of e-mail into daily workflow, such as utilization of office personnel, appears to be a significant area of concern for many of the physicians. For other issues, such as content, efficiency of e-mail, and confidentiality, there were diverging experiences and opinions. Physicians appear to be selective in choosing which patients they will communicate with via e-mail, but the criteria for selection is unclear.
CONCLUSION: These physician respondents did perceive benefits to e-mail with a select group of patients. Several areas, such as identifying clinical situations where e-mail communication is effective, incorporating e-mail into office flow, and being reimbursed for online medical care/communication, need to be addressed before this mode of communication diffuses into most practices.

Despite its potential, the use of e-mail for physician-patient communication has not been widely adopted. Our purpose was to survey the experiences of physicians who are early adopters of the technology. Physicians, identified through a professional Internet information portal, completed a survey, including an assessment of satisfaction with using e-mail with patients. We identified 204 physicians who reported using e-mail with patients on a daily basis. Average age of the respondents was 49 years, 82% were male, and 35% were primary-care physicians. Among the 204 frequent users, commonly reported e-mail topics were new, nonurgent symptoms, and questions about lab results. Despite their daily use, 25% were not satisfied with physician-patient e-mail. The most important reasons for using e-mail with patients among those who were satisfied were "time saving" (33%) and "helps deliver better care" (28%) compared with "patient requested" (80%) among those who were not satisfied (p <.01). Dissatisfied physicians reported concerns about time demands, medicolegal risks, and ability of patients to use e-mail appropriately. Although the majority of these "vanguard" physicians reported benefits, some did not recommend that colleagues adopt this new technology. Increasing integration into practice to enhance time-saving aspects and improve patient education might lead to more sustained use of this promising communication tool.

We surveyed medical house officers at the Beth Israel Deaconess Medical Center during their ambulatory rotations about their utilization of reference materials, assessing such factors as frequency, the mode of reference, and specific choice of resources. The collected data were significantly illustrative of the shift from paper-based resources to digital references. These findings confirm that availability should be of utmost priority when designing references for physicians in training.

BACKGROUND: Although computerized physician order entry reduces medication errors among inpatients, little is known about the use of this system in primary care.
METHODS: We calculated the override rate among 3481 consecutive alerts generated at 5 adult primary care practices that use a common computerized physician order entry system for prescription writing. For detailed review, we selected a random sample of 67 alerts in which physicians did not prescribe an alerted medication and 122 alerts that resulted in a written prescription. We identified factors associated with the physicians' decisions to override a medication alert, and determined whether an adverse drug event (ADE) occurred.
RESULTS: Physicians overrode 91.2% of drug allergy and 89.4% of high-severity drug interaction alerts. In the multivariable analysis using the medical chart review sample (n = 189), physicians were less likely to prescribe an alerted medication if the prescriber was a house officer (odds ratio [OR], 0.26; 95% confidence interval [CI], 0.08-0.84) and if the patient had many drug allergies (OR, 0.70; 95% CI, 0.53-0.93). They were more likely to override alerts for renewals compared with new prescriptions (OR, 17.74; 95% CI, 5.60-56.18). We found no ADEs in cases where physicians observed the alert and 3 ADEs among patients with alert overrides, a nonsignificant difference (P =.55). Physician reviewers judged that 36.5% of the alerts were inappropriate.
CONCLUSIONS: Few physicians changed their prescription in response to a drug allergy or interaction alert, and there were few ADEs, suggesting that the threshold for alerting was set too low. Computerized physician order entry systems should suppress alerts for renewals of medication combinations that patients currently tolerate.

The purpose of our study is to demonstrate the value of CT in the emergency department (ED) for patients with non-traumatic abdominal pain. Between August 1998 and April 1999, 536 consecutive patients with non-traumatic abdominal pain were entered into our study. Using a computer order entry system, physicians were asked to identify: (a) their most likely diagnosis; (b) their level of certainty in their diagnosis; (c) if they thought CT would be normal or abnormal; (d) their treatment plan (prior to knowledge of the CT results); and (e) their role in deciding to order CT. This information was correlated with each patient's post-CT diagnosis and subsequent management. Pre- and post-CT diagnoses were concordant in 200 of 536 (37%) patients. The physicians' certainty in the accuracy of their pre-CT diagnosis was less than high in 88% of patients. Prior to CT, the management plan included hospital admission for 402 patients. Following CT, only 312 patients were actually admitted; thus, the net impact of performing CT was to obviate the need for hospital admission in 90 of 536 (17%) of patients with abdominal pain. Prior to CT, 67 of 536 (13%) of all patients would have undergone immediate surgery; however, following CT only 25 (5%) actually required immediate surgery. Among patients with the four most common pre-CT diagnoses (appendicitis, abscess, diverticulitis, and urinary tract stones) CT had the greatest impact on hospital admission and surgical management for patients with suspected appendicitis. For patients with suspected appendicitis, CT reduced the hospital admission rate in 28% (26 of 91) of patients and changed the surgical management in 40% (39 of 91) of patients. Our study demonstrates the advantage of performing abdominal CT in the ED for patients with non-traumatic abdominal pain.

OBJECTIVE: The problems with access to care and the special needs for educational outreach for disadvantage or vulnerable populations of patients require innovation. This paper describes Baby CareLink use of information technology to support communication, consultation, and collaboration among colleagues as well as with patients, their families, and community resources.
METHODS: In response to the educational, emotional and communication needs of parents of premature infants and the clinicians who care for the infants and support the families, we developed Baby CareLink, a secure collaborative environment. Baby CareLink provides a nurturing environment where parents, even though remote from the Neonatal Intensive Care Unit, can actively participate in decisions surrounding their baby's care.
RESULTS: In a southeastern hospital serving a mostly Medicaid population in a rural setting, more than 300 parents have used Baby CareLink more than 11000 times during the past year. Despite the common wisdom that Medicaid families do not have access to the Internet, approximately 85% of the parents access Baby CareLink from home, at work, from the library or other public access point. The median use of Baby CareLinks from outside the hospital by parents is 17 separate sessions. In a city hospital in the midwestern US which exclusively serves a Medicaid population, experience has been equally encouraging. More than 70 parents have initiated more than 600 secure sessions with Baby CareLink. In contrast to the rural hospital, only 35% of sessions have been initiated outside the hospital.
DISCUSSION: Experience with Baby CareLink suggests that families from all walks of life will use and benefit from collaborative tools that keep them informed and involved in the care of their children. The most significant barrier to wider deployment is bandwidth limitations into the homes of most families. The care of premature infants is a great example of an area where medical knowledge and ability has grown dramatically, and where information and communication technology holds enormous potential.

Patient empowerment is a philosophy of health care that proceeds from the perspective that optimal outcomes of health care interventions are achieved when patients become active participants in the health care process. Under a patient empowerment philosophy, patients and clinicians jointly set goals, select interventions, and assess outcomes according to mutually-defined parameters. Employing patient empowerment as an information systems design philosophy leads to creation of computerized information resources, management systems and telehealth innovations in a manner that insures patients' abilities to participate as full partners in health care. Discussions in the track 3 discussion group led to refinement of the concept from patient empowerment to patient engagement. This report reflects the discussions by the participants.

The user interface of an electronic patient record system can significantly improve user acceptance and ease its adoption process. The design of a user interface should take into consideration the characteristics and the needs of the user incorporating usability engineering principles in the lifecycle of its development. In this paper we describe a study of physician interaction with a paper-based patient record system and a graphical-based electronic patient record system. The usability attributes of learnability, efficiency and satisfaction are evaluated on the whole spectrum of physicians' activities with patient record systems. The results of the study did not reveal a significant difference in the overall time to complete typical physician tasks. However, on average physicians can perform viewing tasks faster, documenting tasks slower and ordering tasks at about the same speed on the graphical-based system than on the paper based system. Physicians were found to be significantly more satisfied with the graphical-based system than with the paper-based system. The results also revealed that physicians with higher levels of computer literacy and typing skills can complete typical tasks in significantly less time on a graphical-based system than physicians with lower levels of computer literacy and typing skills.

OBJECTIVE: To explore family physicians' perspectives on how best to provide evidence-based preventive clinical practice guidelines (CPGs) to physicians on the Internet.
DESIGN: Focus groups.
SETTING: A large, urban centre and a rural community hospital.
PARTICIPANTS: Thirty-four of more than 150 family physicians who subscribed to an e-mail discussion group.
METHOD: Qualitative survey of four focus groups, analysis of transcripts and researchers' notes.
MAIN FINDINGS: Four themes characterized participants' preferences for disseminating preventive CPGs on the Internet: content expectations; quick, easy access to information; trustworthiness of information; and implications for clinical practice.
CONCLUSION: Physicians want quick, easy access to trustworthy information. A website for preventive CPGs with these characteristics would be a useful resource.

OBJECTIVE: To explore how best to make high-quality preventive health information available to consumers on the Internet.
DESIGN: Focus groups.
SETTING: Three urban workplaces and one local hospital with patients from a rural family medical practice.
PARTICIPANTS: Twenty-two men and 17 women patients.
METHOD: Qualitative survey of four focus groups, analysis of transcripts and researchers' notes.
MAIN FINDINGS: Five themes characterized participants' perceptions of a consumer website of evidence-based preventive guidelines: content expectations, website design, trustworthiness of content, marketing, and the implications of consumer health information on the Internet.
CONCLUSION: Consumers want preventive health information both for taking care of themselves and for participating in a more informed way in their health care when they see a physician. Findings of this study reveal some ways in which consumers' use of Internet health information can affect physicians' and other health professionals' work.

Even the most extensive hospital information system cannot support all the complex and ever-changing demands associated with a clinical database, such as providing department or personal data forms, and rating scales. Well-designed clinical dialogue programs may facilitate direct interaction of patients with their medical records. Incorporation of extensive and loosely structured clinical data into an existing medical record system is an essential step towards a comprehensive clinical information system, and can best be achieved when the practitioner and the patient directly enter the contents. We have developed a rapid prototyping and clinical conversational system that complements the electronic medical record system, with its generic data structure and standard communication interfaces based on Web technology. We believe our approach can enhance collaboration between consumer-oriented and provider-oriented information systems.